The sequential changes of the model for end-stage liver disease score correlate with the severity of liver cirrhosis in patients with hepatocellular carcinoma undergoing locoregional therapy

Cryptogenic hepatocellular carcinoma: characteristics, outcome, and prognostic role of albumin-bilirubin (ALBI) grade vs easy ALBI grade

BACKGROUND

The characteristics and prognosis of cryptogenic hepatocellular carcinoma (HCC) remain unclear. The albumin-bilirubin (ALBI) grade and its updated version, the easy ALBI (EZ-ALBI) grade, are important prognostic predictors for HCC. We aimed to investigate the long-term survival of patients with cryptogenic HCC and the prognostic role of ALBI and EZ-ALBI grade in these patients.

METHODS

A prospective cohort of 2,937 HCC patients with viral or cryptogenic etiology were retrospectively analyzed. The multivariate Cox model was used to determine prognostic predictors.

RESULTS

Cryptogenic HCC patients were often older and diabetic, had lower serum ɑ-fetoprotein (AFP) levels, larger tumor burden, poor performance status, advanced cancer stage, and received non-curative treatments compared with hepatitis B or C-related HCC. The Cox analysis showed that age > 65 years, serum AFP > 400 ng/mL, presence of vascular invasion or distant metastasis, presence of ascites, performance status 2-4, ALBI grade 2 and 3, EZ-ALBI grade 2 and 3, and non-curative treatment, were independent predictors of decreased survival in cryptogenic HCC (p < .001). Significant survival differences were found across ALBI grade and EZ-ALBI grade in cryptogenic HCC and subgroup patients receiving curative or non-curative treatments. The Cancer of Liver Italian Program was the best staging system for patients with cryptogenic HCC.

CONCLUSIONS

Patients with cryptogenic HCC have a larger tumor burden and advanced cancer stage at disease presentation compared with those with viral HCC. The ALBI and EZ-ALBI score are robust models to evaluate liver functional reserve for these patients independent of treatment modality.

Albumin-Bilirubin (ALBI) Grade-Based Nomogram for Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization

BACKGROUND/AIM

The prognosis of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE) is highly heterogeneous because of variable characteristics of tumor burden and liver dysfunction. We aimed to propose and validate an albumin-bilirubin (ALBI) grade-based prognostic nomogram for HCC patients undergoing TACE.

METHODS

A total of 1051 patients with HCC undergoing TACE were randomly assigned to derivation (n = 525) and validation (n = 526) set in this retrospective study based on prospective data. The multivariate Cox proportional hazards model in derivation set was used to generate the nomogram. The predictive accuracy of the nomogram was evaluated by discrimination and calibration tests.

RESULTS

In multivariate analysis, presence of ascites, ALBI grade 2-3, serum ɑ-fetoprotein level ≥ 400 ng/mL, total tumor volume ≥ 396 cm³, presence of vascular invasion, and poor performance status were independently associated with decreased survival of patients in the derivation set. Each patient had an individualized score from 0 to 41 by adding up the points from these six prognostic predictors. The nomogram generated from the derivation set had a concordance index of 0.72 (95% confidence interval [CI] 0.63-0.82). Discrimination test in the validation set provided a good concordance index 0.72 (95% CI 0.62-0.81), and the calibration plots consistently matched the ideal 45-degree reference line for 3- and 5-year survival prediction.

CONCLUSIONS

The ALBI grade-based prognostic model can well discriminate the survival in HCC patients undergoing TACE. The proposed easy-to-use nomogram may accurately predict the survival at 3 and 5 years for individual HCC patient in the precision medicine era.

Albumin-bilirubin (ALBI) grade-based nomogram to predict tumor recurrence in patients with hepatocellular carcinoma

BACKGROUND

Tumor recurrence after curative resection is common in hepatocellular carcinoma (HCC), but large-scale long-term prediction on an individual basis has seldom been reported. We aimed to construct an albumin-bilirubin (ALBI) grade-based nomogram to predict tumor recurrence in patients with HCC undergoing surgical resection.

METHODS

A total 1038 patients with newly diagnosed HCC undergoing curative resection between 2002 and 2016 were enrolled. Baseline characteristics, tumor status and severity of liver functional reserve were collected. The Cox proportional hazards model was used to predict tumor recurrence and construct the nomogram. The performance of the nomogram was evaluated by the discrimination and calibration tests.

RESULTS

After a mean follow up time of 30 months, 510 (49%) patients developed tumor recurrence. The cumulative recurrence-free survival at 1, 3, 5, and 10 years were 79%, 51%, 38% and 26%, respectively. In the Cox multivariate model, ALBI grade 2-3, multiple tumors, tumor size equal or large than 2 cm, serum ɑ-fetoprotein level equal or greater than 20 ng/ml and total tumor volume equal or larger than 227 cm³ were independent risk factors associated with tumor recurrence. A nomogram was constructed based on these five variables. Internal validation with 10,380 bootstrapped sample sets had a good concordance of 0.607 (95% of confidence interval: 0.587-0.627). The calibration plots for 1-, 3- and 5-year recurrence-free survival well matched the idealized 45-degree line.

CONCLUSIONS

ALBI is a feasible marker for tumor recurrence. This easy-to-use ALBI grade-based nomogram may predict tumor recurrence for individual HCC patient undergoing surgical resection.

Current noninvasive liver reserve models do not predict histological fibrosis severity in hepatocellular carcinoma

The Ishak scoring system has been used to stage liver fibrosis. Ten noninvasive liver reserve models were proposed to assess the severity of liver fibrosis, but their performance in hepatocellular carcinoma (HCC) is unknown. We aimed to evaluate the correlation between these models and severity of fibrosis in patients with HCC. A total 464 patients with HCC undergoing surgical resection were retrospectively analyzed. Multivariate logistic regression analysis was performed to determine independent factors associated with advanced fibrosis (Ishak score 4 or higher). There were no significant correlations between all noninvasive models and severity of fibrosis in HCC (p for trend all >0.1). In subgroup analysis, cirrhosis discriminant index (CDS) and Lok’s index in hepatitis B-, and fibrosis index based on 4 factors (FIB-4), CDS and Lok’s index in hepatitis C-associated HCC, best correlated with the severity of liver fibrosis. Low platelet count, prolonged prothrombin time, hepatitis C and multiple tumors were independently associated with advanced fibrosis. Among the 10 models, CDS was the best model to predict cirrhosis. Currently used noninvasive liver reserve models do not well correlate with severity of histological fibrosis in HCC. New noninvasive models are required to improve the predictive accuracy of liver fibrosis in HCC.

Comparison of twelve liver functional reserve models for outcome prediction in patients with hepatocellular carcinoma undergoing surgical resection

Various noninvasive liver functional reserve models have been proposed, but their prognostic ability in patients with hepatocellular carcinoma (HCC) is unclear. We aimed to investigate the performance of twelve noninvasive liver reserve models in HCC patients undergoing surgical resection. A total of 645 patients undergoing resection were prospectively identified and retrospectively analyzed. Tumor recurrence, overall survival, and independent prognostic factors were evaluated by the Cox proportional hazards model. Of the twelve models, the King’s score showed the highest homogeneity and lowest corrected Akaike information criterion (AICc) value, suggesting a better predictive ability for tumor recurrence. In multivariate Cox analysis, we confirmed that King’s score, tumor size and serum alpha-fetoprotein level were independent predictors associated with recurrence. In survival prediction, albumin-bilirubin (ALBI) revealed the highest homogeneity and lowest value among twelve invasive models, indicating a better prognostic performance. In the Cox model, ALBI grade, tumor burden, alpha-fetoprotein, vascular invasion, diabetes mellitus and performance status were independent predictors linked with overall survival. In summary, the currently used liver function models have differential predictive ability for HCC patients undergoing surgical resection. The King’s score is a feasible tool to predict tumor recurrence, whereas ALBI grade is a more robust model for prognostic prediction.

Prognostic role of noninvasive liver reserve markers in patients with hepatocellular carcinoma undergoing transarterial chemoembolization

Background

Various noninvasive liver reserve markers were proposed to indicate the severity of liver damage. However, the role and feasibility of these markers to predict the prognosis of patients with hepatocellular carcinoma (HCC) are unknown. We aimed to identify the prognostic role of the 8 currently used hepatic reserve markers in patients with HCC undergoing transarterial chemoembolization (TACE).

Methods

Between 2002 and 2013, a total of 881 patients with HCC undergoing TACE were prospectively identified and retrospectively analyzed. The baseline characteristics, tumor status and noninvasive markers were collected. Homogeneity and corrected Akaike information criteria (AICc) were compared between these markers. The Cox proportional hazards model was used to identify independent predictors of survival.

Results

Significant differences in survival distribution were found for albumin-bilirubin (ALBI) grade, Child-Turcotte-Pugh (CTP) class, Lok index, fibrosis index based on 4 factors (FIB-4), Göteborg University cirrhosis index (GUCI), cirrhosis discriminant index (CDI) and model for end-stage liver disease (MELD) score (all p values <0.05). Among these markers, the ALBI grade showed the highest homogeneity and lowest AICc value, indicating a better prognostic performance. Cox multivariate analysis confirmed that ALBI grade 2, ascites, serum alkaline phosphatase and α-fetoprotein level, tumor diameter, vascular invasion and performance status were significant independent prognostic predictors. The distribution of the ALBI score well correlated with baseline CTP and MLED scores.

Conclusions

Our data suggest that among the currently used liver reserve markers, ALBI grade may serve as an objective and feasible surrogate to predict the prognosis of HCC patients undergoing TACE.

Prognostic prediction across a gradient of total tumor volume in patients with hepatocellular carcinoma undergoing locoregional therapy

Background

The size and number of tumors are important prognostic indicators for hepatocellular carcinoma (HCC). However, it is difficult to assess the prognosis for patients with a variable number and size of tumors. By combining these two factors, we investigated the role and prognostic accuracy of total tumor volume (TTV) for HCC.

Methods

A total of 786 patients undergoing locoregional therapy (transarterial chemoembolization, percutaneous radiofrequency ablation and acetic acid or ethanol injection) for HCC were prospectively evaluated.

Results

The mean and median TTV was 177 cm³ (range, 0.1-3,591 cm³) and 21 cm³, respectively. Of all, 38%, 29%, 15%, 7% and 11% of patients had TTV of <10 cm³, 10-50 cm³, 50-200 cm³, 200-500 cm³ and >500 cm³, respectively. TTV was significantly larger in patients with higher serum α-fetoprotein (AFP) levels or with vascular invasion. The Child-Turcotte-Pugh score, performance status, vascular invasion, AFP level and TTV were significant independent prognostic predictors in the Cox proportional hazards model. After adjustment, patients with TTV 50-200 cm³ (relative risk [RR]: 1.74, p = 0.009), 200-500 cm³ (RR: 2.15, p = 0.006) and >500 cm³ (RR: 3.92, p < 0.001) had a significantly increased mortality risk in comparison to patients with TTV <10 cm³.

Conclusions

TTV is a feasible prognostic predictor across a wide gradient and can be used to predict the mortality risk of HCC. Selecting appropriate cutoffs of TTV may help refine the design of cancer staging system and treatment planning. Future clinical trials of HCC may include this parameter for mortality risk stratification.

Transcatheter arterial chemoembolization for liver cancer: is it time to distinguish conventional from drug-eluting chemoembolization?

Conventional transcatheter arterial chemoembolization and chemoembolization with drug-eluting beads are increasingly being performed interchangeably in many institutions throughout the world. As both therapies continue to being tested in many phase II and III studies and in combination with other therapies, especially targeted agents, for treatment of primary and metastatic liver cancer, it is imperative to review their current status and evaluate their impact on patient survival. This review critically assesses patient selection, indications, contraindications, techniques, materials, safety, and clinical outcomes of patients treated with conventional chemoembolization and chemoembolization with drug-eluting beads.

Transarterial chemoembolization in patients with hepatocellular carcinoma and renal insufficiency

BACKGROUND

Renal dysfunction is often present in patients with cirrhosis and hepatocellular carcinoma (HCC). Acute renal failure (ARF) may occur after transarterial chemoembolization (TACE) owing to radiocontrast agent. This study investigated the incidence and risk factors of ARF and prognostic predictors in HCC patients with preexisting renal insufficiency undergoing TACE.

METHODS

A total of 566 HCC patients undergoing TACE were enrolled. Renal insufficiency was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m.

RESULTS

In a mean follow-up duration of 18+/-16 months, 231 (40.8%) patients undergoing TACE died. Renal insufficiency that was present in 134 (23.7%) patients at baseline, independently predicted a poor prognosis in the Cox proportional hazards model [risk ratio (RR): 1.47, P=0.012]. Of them, 13 (10%) and 6 (5%) patients had transient and prolonged ARF after TACE, respectively. Post-TACE gastrointestinal bleeding [odds ratio (OR): 16.54, P=0.001] and higher Cancer of the Liver Italian Program (CLIP) scores (> or =2; OR: 4.22, P=0.02) were independent risk factors for ARF in the multivariate logistic regression analysis. In the Cox model, prolonged ARF (RR: 3.28, P<0.001) and higher CLIP scores (> or =2; RR: 2.13, P<0.001) were independent poor prognostic predictors for HCC patients with renal insufficiency receiving TACE.

CONCLUSIONS

Gastrointestinal bleeding and higher CLIP scores are associated with the development of ARF in patients with HCC and renal insufficiency undergoing TACE. Higher CLIP scores and renal insufficiency, either preexisting before TACE or as a complication of TACE, are poor prognostic predictors in HCC patients receiving TACE.

Selecting a short-term prognostic model for hepatocellular carcinoma: comparison between the model for end-stage liver disease (MELD), MELD-sodium, and five cancer staging systems

BACKGROUND

The model for end-stage liver disease (MELD) and MELD-sodium (MELD-Na) are prognostic models for cirrhotic patients with or without hepatocellular carcinoma (HCC). This study compared the predictive accuracy between the MELD, MELD-Na, TNM (tumor, node, metastasis), Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), Japan Integrated Scoring (JIS), and Tokyo score for 3-month and 6-month mortality in HCC patients.

METHODS

A total of 953 patients were prospectively enrolled. The predictive accuracy was compared between different models using the area under receiver operating characteristic curve (AUC).

RESULTS

The CLIP system had the highest AUC (0.875) for predicting 3-month mortality, followed by the Tokyo score (0.874), JIS (0.868), BCLC (0.855), MELD-Na (0.829), MELD (0.803), and finally, TNM (0.795) system. At 6 months, the top 3 models and their AUCs were the CLIP (0.882), Tokyo (0.861), and JIS (0.85). MELD-Na consistently had significantly better predictive accuracy than the MELD at 3 and 6 months. The MELD and MELD-Na were better prognostic models in predicting the mortality for surgical patients (AUC, 0.719 to 0.740), whereas the CLIP and Tokyo systems were the 2 better models in staging nonsurgical (AUC, 0.849 to 0.884) and high-risk patients (AUC, 0.790 to 0.846), defined as having at least 2 independent risk factors of mortality, at 3 and 6 months.

CONCLUSIONS

The MELD-Na may improve the prognostic ability of the MELD system for patients with HCC. Both the CLIP and Tokyo systems are better short-term prognostic models. These findings are helpful in designing future clinical trials for HCC.

The MELD-Na is an independent short- and long-term prognostic predictor for hepatocellular carcinoma: a prospective survey

BACKGROUND AND AIM

Serum sodium has been suggested to incorporate into the model for end-stage liver disease to enhance its prognostic ability for cirrhosis. A mathematical equation based on model for end-stage liver disease and sodium, known as "MELD-Na", was developed for outcome prediction for cirrhosis. The severity of liver cirrhosis is a key component to predict survival in patients with hepatocellular carcinoma. This study investigated the prognostic role of MELD-Na for hepatocellular carcinoma.

PATIENTS AND METHODS

A total of 535 unselected hepatocellular carcinoma patients were prospectively enrolled to evaluate the performance of MELD-Na.

RESULTS

The MELD-Na was better than model for end-stage liver disease in predicting 6-month mortality by comparing the area under receiver operating characteristic curve (0.782 vs. 0.761, p=0.101). MELD-Na, but not model for end-stage liver disease, was an independent predictor associated with 6-month mortality in multivariate logistic regression analysis (odds ratio: 1.14, p=0.001). In the survival analysis, MELD-Na also independently predicted mortality, with an additional risk of 4.3% per unit increment of the score (p<0.001). Patients with MELD-Na scores between 10 and 20 and scores >20 had 2.1-fold (p<0.001) and 7.5-fold (p<0.001) risk of mortality, respectively, compared to patients with a score <10 in the Cox proportional hazard model.

CONCLUSION

The MELD-Na score is a feasible and independent prognostic predictor for both short- and long-term outcome predictions in patients with hepatocellular carcinoma.

Validation of the HCC-MELD for dropout probability in patients with small hepatocellular carcinoma undergoing locoregional therapy

BACKGROUND

The model for end-stage liver disease (MELD) is used in prioritizing cirrhotic patients awaiting liver transplantation. Patients with small hepatocellular carcinoma (HCC) are eligible candidates. An HCC-MELD equation was recently proposed to predict the dropout rate of HCC patients on the waiting list. This study aimed to validate the accuracy of this equation.

METHODS

We investigated 390 patients with small HCC who were candidates for liver transplantation and underwent locoregional therapy.

RESULTS

The estimated probability of dropout according to the equation was 8.2% for T1 stage and 13.5% for T2 stage HCC (p < 0.0001). The actual disease progression rate at three months was 2.1% for T1 and 3.0% for T2 stage HCC. At six months, the progression rate was 5.3% for T1 stage and 6.8% for T2 stage. The area under receiver operating characteristic curve of the HCC-MELD equation was 0.81 at three months and 0.80 at six months. Patients undergoing radiofrequency ablation (RFA) had significantly lower dropout rates compared with other treatment groups according to the equation (p = 0.0007). The actual tumor progression rate was also the lowest for the RFA group at both three and six months.

CONCLUSION

The HCC-MELD equation is a feasible predictive model for patients with small HCC undergoing locoregional therapy.

Correlation and comparison of the model for end-stage liver disease, portal pressure, and serum sodium for outcome prediction in patients with liver cirrhosis

BACKGROUND

The model for end-stage liver disease (MELD), hepatic venous pressure gradient (HVPG), and serum sodium (SNa) are important prognostic markers for patients with liver cirrhosis. The correlation among these markers and their predictive accuracy for survival are unclear.

METHODS

A total of 213 cirrhotic patients undergoing hemodynamic measurement were analyzed. The correlations between MELD score, SNa, and hemodynamic parameters were investigated.

RESULTS

There was a significant correlation between MELD and HVPG (r=0.255, P<0.001), between SNa and MELD (r=-0.483, P<0.001), and between HVPG and SNa (r=-0.213, P=0.002). Using mortality as the end-point, the area under receiver operating characteristic curve (AUC) for MELD was 0.789, compared with 0.659 for HVPG (P=0.165) and 0.860 for SNa (P=0.34) at 3 months; the difference between HVPG and SNa was significant (P=0.015). The AUC at 6 months was significantly higher for SNa and MELD compared with that of HVPG. Among 134 patients with low (<14) MELD scores, a high (>16 mm Hg) HVPG, and low SNa (<135 mEq/L) predicted early mortality. In the Cox multivariate model, MELD, HVPG, and Child-Turcotte-Pugh scores were consistently identified as independent poor prognostic predictors when they were treated either as dichotomous or continuous variables in the model.

CONCLUSIONS

MELD score is closely associated with HVPG and SNa in cirrhotic patients. HVPG is not superior to MELD score or SNa for short-term outcome prediction. High HVPG and low SNa may identify high-risk patients with low MELD scores. High MELD, HVPG, and Child-Turcotte-Pugh scores are independent predictors of poor long-term survival.